The document discusses sexual assault, including definitions, statistics, forms of assault, risk factors, and protocols for managing assault in Malawi. It provides background on sexual assault and its health effects. It then outlines forms of assault like rape, harassment, and child abuse. Risk factors for victims and perpetrators are identified. The management protocol describes examining victims, investigations, treatments, counseling, and referrals to support services.

2.  Background
 Effects of sexual assault
 Forms of sexual assault
 Risk factors to sexual violence
 Protocol for rape management
 Malawi-Reproductive Health Rights
 references

3.  Sexual assault is defined as:
“any sexual act, attempt to obtain a sexual act,
unwanted sexual comments or advances, or
acts to traffic women’s sexuality, using
coercion, threats of harm or physical force, by
any person, regardless of the relationship with
the victim, in any setting, including but not
limited to home, school, prison, the streets and
at work’.
(World Health Organisation 2003)

4.  Statistics:
› Nearly 1 in 5 (18.3%) women and 1 in 71 men (1.4%)
reported experiencing rape at some time in their lives.
› Approximately 1 in 20 women and men (5.6% and 5.3%,
respectively) experienced sexual violence other than
rape, such as being made to penetrate someone else,
sexual coercion, unwanted sexual contact, or non-
contact unwanted sexual experiences, in the 12 months
prior to the survey.
› 4.8% of men reported they were made to penetrate
someone else at some time in their lives.
› 13% of women and 6% of men reported they experienced
sexual coercion at some time in their lives.
 (CDC)

5.  Malawi:
› 24% of all school children aged 9-18 years
old have been forced to have sex, mostly at
home and at school
One stop center
on average a case is reported everyday

6. › unwanted pregnancy
› Sexual dysfunction
› unsafe abortion
› Infertility
› STIs including HIV/AIDS
› Pelvic pain and urinary tract infections
› Post traumatic stress disorder
› Self harm
› Suicide
› Flashbacks
› Eating disorders
› depression
› Substance abuse

7.  Rape:
› “physical forced or otherwise coerced penetration – even if slightly – of
the vulva or anus, using a penis, other body parts or an object” (World
Health Organisation 2003)
 Sexual harassment:
› Intimidation, bullying or coercion of sexual nature, or unwelcome or
inappropriate promise or rewards in exchange of sexual favors.
 Groping
› Touching or fondling of another person in sexual way without that
person’s consent
 Elderly sexual assault :
› Sexually victimization of elderly individual (60)
 Child sexual abuse:
› Involves an adult or order adolescent sexualy abusing a child(asking or
pressuring a child to engage in sexual activeities, indesent exposure of
genitals to a child)
 Domestic violence:

8.  Who are the victims?
› Women
› Children
› Orphans
› men

9.  perpetrators:
› Family members
› Neighbors
› Strangers
› seniors

10.  CDC
› In a nationally representative survey;
 Among female rape victims, perpetrators were
reported to be intimate partners (51.1%), family
members (12.5%), acquaintances (40.8%) and
strangers (13.8%).
 Among male rape victims, perpetrators were
reported to be acquaintances (52.4%) and
strangers (15.1%).
 Among male victims who were made to
penetrate someone else, perpetrators were
reported to be intimate partners (44.8%),
acquaintances (44.7%) and strangers (8.2%).

11. Women being victimized
› being young;
› consuming alcohol or drugs;
› having previously been raped or sexually
abused;
› having many sexual partners;
› involvement in sex work;
› becoming more educated and
economically empowered;
› poverty.

12.  Diagnosis
› History Record details of the events before
and after the assault, drugs taken voluntarily
or involuntarily, force and/or weapons used,
condom use, timing and sequence of
events, specific events of the assault and
post assault hygiene. Ask about LMP, current
hormonal contraception and previous
intercourse.

13.  Physical examination
› Visualize entire body to draw a detailed body
map. Mark abnormalities (i.e. contusions, bites,
ligature marks, old and new trauma),
distinguishing features (i.e. tattoos, piercings,
scars) and areas where swabs were obtained.
Include pertinent negatives. For the pelvic exam,
visualize before using a speculum. Other
common areas of injury include head/neck and
anus/rectum. Note tenderness, tears,
ecchymosis, abrasions, erythema and oedema.
Lack of findings does not mean that the exam is
inconsistent with history of sexual assault.

14.  Investigations
› Time dependent specimens include
sperm/semen, foreign material, swabs of
body secretions and fingernail scrapings.
Blood and hair from the head or pubic area
are NOT time dependent. Also do the
following:
› HIV test
—Pregnancy test

15.  Management
 Step 1:
› Assess and treat serious injuries first
› Obtain verbal consent to conduct physical examination
› Take full history and document all findings
› Conduct full physical examination and document all findings
› Document all facts regarding the assault
 Step 2:
› Manage physical effects of the assault such as wounds and bruises –
including antibiotics to prevent wound infection, tetanus booster if
required, medication for pain relief or anxiety
 Step 3:
› Provide emergency contraception if the victim has started menarche
and presents within 72 hours post-assault
› Postinor-2 – take 1 tablet orally, to be repeated after 12 hours or
› Lo-Femenal 4 tabs to be repeated after 12 hours

16.  Step 4:
› Treat presumptively for STIs (or conduct laboratory investigations if
available):
› Benzathine Penicillin < 25 kg: 600,000 IU stat (if >25 kg, then 1,200,000 IU
stat)
› Gentamycin 6mg/kg single dose
› Erythromycin 12.5mg/kg every 6 hours for 7 days
› Metronidazole 5mg/kg every 8 hours for 7 days
 Step 5:
› Provide HIV Testing and Counseling
› Conduct an HB baseline reading (if available)
› If the victim presents within 72 hours of penetrative assault, and is HIV
negative upon initial testing, and consents to PEP treatment, provide PEP
treatment with Duovir BD x 30 days.
› o If the victim has HB ≤ 8 g/dl Duovir must be replaced with LamivirS BD x
30 days
› Malawi Obstetrics & Gynaecology Protocols Page 102

17.  Step 6:
› Provide counseling on post-traumatic stress to victim
and guardian
› Assess safety of the victim
› Refer to other support services, such as the Victim
Support Unit in the Police
 Step 7:
› Advise on dates for follow up visits
› Record Findings and treatment in “Examination
Record” and provide copy to the victim for
submission to the police, if appropriate
› Record all findings and treatment in health passport

18.  The right to be free from sexual assault and
exploitation
 Right to life and survival.
 Right to liberty and security of person.
 the right to highest attainable standard of health, reproductive
health, and family planning
 the right to decide the number and spacing of children
 The Right to decide freely and responsibly the number and
spacing of one’s children and to
 have the information and means to do so.
 the right to marry and to found a family
 the right to life, liberty, and security
 the right to be free from gender discrimination
 the right to modify customs that discriminate against women
 the right to privacy
→This means it is a crime to assault one
sexually(rape)

19.  WHO
 Plan malawi
 Malawi medical journal
 Obstetrics & Gynecology Protocols and
Guidelines; taulo et el
 CDC
 Clinical gynecology 3rd edition tf Kruger,
mh Botha
 www.rainn.org